New Medicaid policy cutting people off from vital drugs

Saturday

Oct 27, 2012 at 12:01 AMOct 27, 2012 at 11:44 AM

SPRINGFIELD -- Thousands of low-income Illinoisans are going weeks without essential medicines, and some are ending up in emergency rooms, because of Illinois’ new limits on prescription drugs for Medicaid patients, doctors and other advocates say.

DEAN OLSEN

SPRINGFIELD -- Thousands of low-income Illinoisans are going weeks without essential medicines, and some are ending up in emergency rooms, because of Illinois’ new limits on prescription drugs for Medicaid patients, doctors and other advocates say.

“We have signs that the program is having some negative, unintended consequences that could drive up health-care costs and put people in dangerous situations,” said Dr. Carrie Nelson, president-elect of the Illinois Academy of Family Physicians.

As many as 200,000 Illinois adults and children on Medicaid, a public insurance program funded jointly by the state and federal governments, eventually will be subject to a potential four-prescription limit as part of budget-cutting legislation signed into law by Gov. Pat Quinn.

Even though state officials say it shouldn’t be happening, essential medicines are being denied by the state, and patients sometimes are being asked by pharmacists which four drugs they want to receive and which they can do without, according to doctors.

“This is not working, and the state is not going to save money,” said Dr. Daniel Yohanna, vice chairman of the department of psychiatry and behavioral neuroscience at the University of Chicago. “I’m concerned that people will have serious ill effects from these changes and even death.”

Doctors and nurses complain they face jammed phone lines and occasional refusals when they seek approval from the state for more than four prescription drugs.

“I am expecting that we will have patients who end up in the clinic, in the emergency room or in the hospital because of this,” said Dr. Harald Lausen, a family physician at Springfield’s Southern Illinois University School of Medicine. “What the impact is going to be, we don’t know yet.”

Lausen and Nelson, a Carol Stream physician, want the Illinois Department of Healthcare and Family Services and the General Assembly to scrap the restrictions or make immediate changes, even though the drug limits are expected to save $180 million this fiscal year and help the state cut $1.6 billion from a Medicaid program on the brink of collapse.

HFS director Julie Hamos said Friday her department is doing its best to cautiously implement the new drug policy and has taken action recently to speed up the approval process.

“We were required to implement 62 different changes very quickly,” Hamos said. “We didn’t have six months to plan this out.

“It did kind of overwhelm the system, and we are working hard to rectify the problems as we find them,” she said.

Appeals possible

Hamos stressed that the four-drug policy isn’t a firm limit. She said it can be exceeded, in some cases, through appeals from patients’ doctors.

She didn’t rule out the possibility of seeking approval from the General Assembly to give automatic approval to a broader range of drugs than what currently is allowed. But she said HFS won’t seek a repeal of the drug limits because the new evaluation process helps determine which drugs are really necessary.

That process, she said, can improve both Medicaid patients’ health and the state’s financial health.

“That is a good thing for Medicaid clients, but the transition to get from here to there is very challenging,” she said.

HFS began Friday to send notices to doctors, pharmacies and others to reduce confusion about the policy and explain what the state is doing to streamline the processing of prior approvals. The notice can be seen at http://tinyurl.com/ilhfsrx.

For example, HFS is encouraging more providers to use an online system rather than telephones or faxes, though Yohanna said the online system is complicated and intimidating to use.

And HFS officials recently decided to exempt children from the limits, at least for now.

It’s unclear how health-care providers will react to the HFS notice.

Twelve pages of complaints submitted to state officials by the Community Behavioral Healthcare Association of Illinois document dozens of individual problems resulting in psychiatric patients being denied medications or facing intolerable delays.

Suicidal thoughts, psychosis

“Consumers that have been denied their medications are experiencing increased suicidal thoughts, higher levels of psychosis, depression and anxiety,” the association stated in the document, which can be read at http://tinyurl.com/rxlimit. “The number of people with mental illnesses being denied their meds will very shortly result in increased admits to the emergency rooms, increased hospitalization, an upswing in incarceration rates, increased substance abuse (and) greater numbers of homelessness.”

Illinois Hospital Association spokesman Danny Chun said Medicaid patients are starting to appear in emergency rooms seeking treatment for conditions that have flared up because they have had to go without their medicine.

“I can’t tell you how widespread it is,” Chun said.

State Sen. Heather Steans, D-Chicago, a sponsor of the law, said Friday she also has begun to hear complaints.

It’s too soon to decide whether the drug limits need to be tweaked, she said.

“Clearly, the implementation is broken right now,” Steans said. “Everyone should be getting the medications they need.”

Lausen said hundreds of patients who use Southern Illinois University School of Medicine’s family-medicine clinic in Springfield have had to wait for weeks for blood-thinning medicine and drugs for high-blood pressure, diabetes, asthma, heart failure and breathing problems.

Some patients may have been denied because doctors aren’t informed by the state whether their pleas for more prescriptions have been granted, Lausen said.

‘Really scary’

Springfield resident Ronnie Beck, 57, an unemployed former cashier and maid who is disabled by arthritis, diabetes and various injuries, said she went without medication for chronic pain for a month before an SIU nurse spent 90 minutes on the phone with the state to get approval for the drugs.

The approval is effective for only two months, Beck said, and 10 other drugs — to treat high cholesterol, arthritis, ulcers and bladder problems — remain denied by Medicaid. Some of the medicine helps her avoid becoming nauseous and vomiting after she eats.

“It’s really scary,” Beck said. “There are a lot of things that could go wrong with my health if I don’t get my meds. I’ve worked two and three jobs most of my life. It’s not like I’ve asked to be where I’m at.”

Illinois is one of about 15 states that have imposed drug limits for Medicaid patients, with the limits ranging from three to eight prescriptions per month.

As recently as late August, Illinois was imposing the four-drug limit on patients receiving 10 or more prescriptions — about 78,300 people.

Jim Parker, HFS’ deputy director for medical programs, said HFS began scrutinizing patients with eight or more prescriptions Oct. 2, but was quickly overwhelmed with requests for prior approval. To ease the backlog, the department on Oct. 19 changed course and limited the scrutiny to patients with nine or more medicines — about 80,000 people.

Hamos said she doesn’t know when HFS will begin to review patients with fewer than nine prescriptions.

Because problems persist, Stephanie Altman, policy director for Chicago-based Health & Disability Advocates, said she is telling patients who have been denied medicines to go to hospital ERs and ask to be handed pills.

“It’s definitely a mess,” Altman said.

More automatic approvals

Altman and Lausen said they would like to see the state expand its list of drugs that are automatically approved. Those drugs currently include contraceptives, anti-virals and cancer-fighting medicine, but the list doesn’t include prescriptions for chronic illnesses such as high blood pressure, diabetes and asthma.

Dr. Renee Poole, a family physician on the south side of Chicago, said she understands the intent of the limits is to reduce waste in the Medicaid program, but the state must make it easier for doctors and patients to receive life-sustaining medicine.

The state July 1 stopped covering a class of drugs called benzodiazepines, such as Valium and Xanax, which are expensive and treat severe anxiety, Yohanna said. But other drugs often aren’t as effective, he said.

Dr. Dora Ramos, medical director of Springfield’s Capitol Community Health Center, said some patients there went for weeks without important medicines such as insulin because of the new policy, though she said processing of drug-approval requests has improved recently.

“I think everybody is trying to do their best to make it work one way or the other,” she said. “It’s a complicated system. I wonder whether this will end up being more expensive if people end up in the ER.”

Springfield resident Shawnetta Henderson, 41, who has diabetes, thyroid problems, asthma and fluid-retention problems, said she has had several prescriptions approved and others denied by Medicaid ,despite her doctors’ requests.

“I need them all, and I take them all,” she said. “I’m concerned because I’m going through a whole lot.”

Dean Olsen can be reached at (217) 788-1543. Follow him at twitter.com/deanolsen.

At a glance: Problems with Illinois’ new Medicaid drug policy

What: The Illinois Department of Healthcare and Family Services is evaluating and potentially refusing to fill doctors’ prescriptions for Medicaid patients who receive more than four medicines per month. The policy is causing headaches for patients and doctors who say essential medicines are being denied, and there have been long waits on “prior approval” requests by the state for more than four prescriptions.

The state’s response: Officials say the policy is in patients’ best interest and that HFS is doing its best to implement the policy as required by the Illinois General Assembly, but has been overwhelmed by prior-approval requests. They have taken steps to process requests quicker and reduce confusion among pharmacies and other health-care providers about how the policy works. The state also has stopped considering children’s prescriptions for denial.